Working to head off a collapse
New Year's hope: Crisis is addressed
Public Health Paradox
By ROB MOSBACHER - Houston Chronicle
Among the many advantages of living in the Houston area, perhaps the greatest is the fact that this is home to some of the finest medical talent and facilities of any city in America.
We are justifiably proud of pioneers like Dr. Michael DeBakey and Dr. Denton Cooley, who have done so much to fight heart disease, and top-rated institutions like M.D. Anderson in the Texas Medical Center.
Given that rich heritage, it is all the more paradoxical that we have a public health delivery system that is facing such a serious crisis and is in danger of collapse unless bold new measures are taken to address it. Fortunately, on Dec. 21, Harris County Commissioners Court voted to take the first bold step by creating a Public Health Care System Council. Let's look at some of the factors that have prompted this deep concern and led the commissioners to act.
More than 30 percent of our population has no health insurance, even though more than two-thirds of those people are working or have a working head of household. That 30 percent figure is twice the national average and is increasing every day.
For a community of 3.5 million, we have so few primary, preventive and specialty care clinics that the only real option for many is the hospital emergency room. Whether it is an ear infection or a massive heart attack, these individuals are all in the emergency rooms; under federal law, they are all entitled to be examined.
This has created such frequent overcrowding of our emergency rooms that they are on diversion, or drive-by status one-third of the time. That means there is no more capacity to treat additional patients, whether insured or not, no matter how serious their injury or illness. If you are the victim of an automobile accident resulting in traumatic head injuries, you want to be taken to one of the two Level One trauma facilities at Ben Taub or Memorial-Herman hospitals. And yet, if their emergency rooms are full of people with less serious injuries, you will be diverted elsewhere.
Moreover, emergency room care is extremely expensive relative to other forms of care that might be more appropriate for one's injury or illness. It costs, on average, three times as much to treat a patient in the emergency room as it does in a more appropriate setting, such as an outpatient specialty clinic. In the Houston area, it is estimated that 57 percent of the people who visit emergency rooms have minor, or non-urgent conditions.
Every uninsured person who enters an emergency room and is treated represents an expense for which the hospital receives little or no compensation. If these patients entered a facility operated by Harris County, the cost of their treatment is borne by county taxpayers. If, however, they entered a private or nonprofit hospital, their expense must be recouped elsewhere. That prompts health care providers that are not public institutions to shift the cost of the uninsured patients to the paying customers. That means that those who are insured must also shoulder a share of the burden of paying for the uninsured.
This, in turn, affects the profit margins of insurance companies, prompting increases in premiums. Constantly increasing premiums forces businesses that provide insurance for their employees to reassess the extent and cost of their coverage. Do employers simply absorb these steady increases in costs, or do they attempt to mitigate those costs by reducing coverage?
While some employers are able to maintain coverage for their employees, many others are not. They raise deductibles or co-pays, they eliminate or reduce coverage for employee dependents, or they stop providing health benefits for their employees altogether. This phenomenon is faced most acutely by small businesses that represent the vast majority of businesses, particularly in the Houston area.
As employers cut back or eliminate their employees' health benefits, the pool of uninsured increases, thereby shifting the costs from that employer to other employers. It is that cost-shifting or hidden tax that is forcing many employers to further reduce health insurance, thereby adding to the ranks of the uninsured, and continuing the vicious cycle.
Against this backdrop, the Greater Houston Partnership, working in cooperation with Harris County and the city of Houston, formed a Public Health Task Force. This 19-member task force includes County Judge Robert Eckels, Commissioner El Franco Lee, Mayor Bill White, public and private health service providers, medical school representatives and business and community leaders. The charge to the task force was to recommend ways to provide more effective access to, and more efficient use of, available health resources. Ultimately, more than 200 people participated in the development of the recommendations. Our recommendations fell into four categories.
•First, in order to make the very best use of every tax dollar currently being spent on health care, the task force recommended that all public health and health care services should be provided through a single consolidated entity with control over and accountability for the full continuum of services currently offered through the existing five public agencies. Four of those agencies are funded by the county and one by the city. The county agencies include: the Hospital District, the Public Health and Environmental Services, the Mental Health Mental Retardation Authority and the Pyschiatric Center. Harris County spends around $1.2 billion annually on public health. The city of Houston has a Health Department that spends about $100 million per year and provides many of the same services that are provided by the county.
While the task force recognizes that such consolidation would take time and require careful planning, we believe the creation of a single form of governance would vastly increase coordination, collaboration and communication among agencies. Moreover, it would enable our community to establish clear and compelling community goals and priorities, rather than individual agency goals and priorities. We also believe that the private and nonprofit providers of health care services in our community must work much more cooperatively together, and in the last several months, that has begun. •Second, the task force recommended employing the latest technology available to wire the major health care providers together. Specifically, we called for the creation of a Community Health Information Network that would link all public health care providers together and then add the private and nonprofit providers. Under this proposal, if a pregnant woman had sought care in a clinic anywhere in the county, and then appeared at a major hospital for the first time to deliver her baby, that hospital would have the ability to pull up any prior medical history. By so doing, they could avoid administering various tests a second time, or be aware of any potential complications already detected.
In addition to providing access to patient histories, the Community Health Information Network would also permit consolidated billing records and program eligibility criteria.
•Third, the task force recommended a variety of initiatives to increase as quickly as possible the number of community-based outpatient clinics that would provide preventative, primary, and specialty care. These sites would take an enormous amount of pressure off the emergency rooms and provide people greater access to medical care in their neighborhoods. While the county already has plans to increase from 11 to 20 the number of clinics they operate, we also recommended expanding the use of school-based clinics and telemedicine. We urged the expansion of mental health capacity by co-locating mental and physical health services in the same clinics, and we recommended using more retired and volunteer physicians.
One the principal health care initiatives of the Bush administration has been to expand the availability of community health care by funding the creation of Federally Qualified Health Centers (FQHCs). These are clinics that provide a host of primary care services to people living in underserved areas. These FQHCs receive substantial reimbursement from the federal government for various services, as well as block grants to help build capacity.
Unfortunately, our community only recently became engaged in the pursuit of FQHCs. So far, we have two. The Greater Chicago area, which has roughly the same population and has been at this much longer, has more than 80. Cities like Chicago are not only getting their share of federal health care dollars, they are also getting ours. However, the Gateway to Care initiative is working to make up for lost time.
•Finally, in order to reduce the burden of escalating costs on county taxpayers and employer-sponsored health insurance providers, we must find creative ways to increase the number of people who have health insurance and can pay for part or all of their care. We suggest that a variety of strategies be employed.
The task force recommended that public programs such as the Children's Health Insurance Program (CHIP) and the Medicaid waiver program be used to maximum advantage. Under the CHIP program, middle- to lower-income kids get health insurance and the state receives around $2.65 from the federal government for every dollar of state investment. Under the Medicaid waiver program, we could leverage about $110 million of county tax dollars that are already being spent for indigent health care, draw down $160 million of federal money and provide Medicaid coverage to approximately 100,000 lower income Houstonians. That represents almost 10 percent of the estimated uninsured population.
We also recommend the development of lower cost private insurance products for individuals and small businesses. Such a product might cost $125 per month or $1,500 per year and provide basic primary care coverage as well as up to $20,000 of hospitalization. In order for such a product to work economically, it must have at least 10,000 subscribers, which could be achieved by encouraging small businesses to band together. It would require a combination of employer and employee contributions.
Every reasonable option should be explored because whatever the investment of public or private dollars to insure more people, it will be less than we are currently spending, or will spend in the future, to care for an uninsured population that is rapidly growing and threatens to overwhelm the system.
Although a few of the task force's recommendations require state legislative or administrative action, most of the changes suggested are up to the Harris County Commissioners Court and, to a lesser extent, the city of Houston.
Commissioners Court's vote last month to create a Public Health Care System Council is a crucial first step. The council, composed of a broad cross-section of health care providers and other representatives, will advise commissioners and make recommendations for the envisioned comprehensive, coordinated public health care delivery system. It is a great way to start the New Year.
Mosbacher, a Houston businessman, is chairman of the Greater Houston Partnership and the Public Health Task Force. |
